A psychiatrist's treatment of a man who was having suicidal thoughts, and who died after his second consultation, has been criticised as not adequate.
In a report today, Mental Health Commissioner Kevin Allan said the psychiatrist did not assess the man's risk adequately at the second and last assessment and should have admitted him for mental health care, either voluntarily or under the Mental Health Act.
Mr Allan said the man, called 'Mr A' was brought into an unnamed hospital emergency department by his parents in late 2011 with testicular pain.
No testicular problem was discovered, but staff identified that he was anxious and depressed with "suicidal ideation" - suicidal thoughts.
Two community psychiatric nurses assessed the man as a low-to-moderate risk to himself and a low risk to others, asking as well for a psychiatric assessment for possible admission to a ward.
A psychiatrist saw him in the evening of the day he presented at the emergency department and formed the impression he had "major depression". However, he said there was no evidence of risk and sent him home with his parents, anti-depressant medication, and an instruction to return the next day for further assessment.
The man's mother, Mrs B, said this came as a surprise, and she felt that she and her son were "fobbed" off by the psychiatrist, Dr C.
On the following day, Dr C found the assessment process difficult and there was "shallow rapport" between him and the patient, Mr Allan said.
Dr C said Mr A's mood was "depressed and angry".
He added, "At this point in time there is some level of concern of suicidal ruminations and feelings of hopelessness, but it does not appear to be significant enough to warrant immediate admission".
He said if he admitted Mr A against his wishes, it would be likely to lead to an escalation of behaviours, "which in turn would meet resistance and force to maintain a level of control and safety for everyone involved".
Mr A went home with his parents and was expected to continue with his anti-depressant medication, increasing the dose in three or four days' time if there was insufficient response.
Dr C also suggested ongoing follow-up of the testicular pain with his GP and consideration of counselling in the community. Dr C sent a copy of his assessment notes to the GP but no other information.
Mr A's father, Mr B, says he was never asked his opinion and they left feeling very concerned and with no idea what was wrong with their son.
At home later that day, Mr A left the house while Mr and Mrs B were discussing what to do. Mr A was involved in an incident that resulted in injuries causing his death. The Coroner said the evidence was not sufficient to establish that Mr A had tried to take his own life.
In his report, Mr Allan said his own findings should not be interpreted as having any implication as to the cause of Mr A's death. However, he said Dr C should have involved Mr A's parents more and should have assessed Mr A's level of risk more, including fully exploring the risk of not admitting him. "I am also critical that, having decided not to admit Mr A, Dr C failed to arrange ongoing specialist follow-up, and did not provide clear, specific guidelines to Mr A's GP."
He recommended Dr C apologise and undertake further training on communication with patients and professional development on clinical assessment.